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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> {� �,J <br /> 06 16 <br /> VWNER/OPERATOR flypN (9T4 t'- <br /> �n CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESSl/ <br /> Street Number Direction Street Name city Zip Cade <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 7 11 /J T/ )170 AV e <br /> Street Number / v treet Name r <br /> CITY Ji ` CA STATE ZIP <br /> 7-G)t,/ �5-;,,/1 <br /> PHONE,#t Tq T APN# �1 LAND USE APPLICATION# <br /> PHONE#2T BOS DIS^^T,,RICT LOCATION CODE <br /> ( ) V� <br /> CONTRACTOR SERVWt REQUESTOR <br /> REQUESTOR 1 <br /> Uq�// <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ]„ FYIG„'k PHON�# 53w 9S <br /> HOME Or MAILING ADDRESS �f A )` ���� FA%# <br /> / / ( ) <br /> CITY GGtC �� STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standa�;� <br /> ERAL laws. I <br /> APPLICANTS SIGNATU\Rr�E: DATE: 1` 7 <br /> PROPERTY/BUSINESS OWNER IGS OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,Proof Of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment inipg <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon a5 It Is available and at the same time It IS provided 66 z1v <br /> my representative. —Asir ri' <br /> 71 <br /> TYPE OPSERACE REQUESTED: /��})® <br /> COMMENTS: SAN dT - 201/ <br /> ' ff ( OAQUIN Co <br /> HEALTH p NM NTq�Ty <br /> EPq TIAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> LV <br /> Date Service Complet (if already completed): SERVICE CODE: O I PIE: <br /> Fee Amount: QO Amount Paid /52—d� Payment Date q/Zy�7 <br /> 7— i <br /> Payment Type ,Z-v. Invoice# Check# '-?rll)s q� Received By: <br /> i <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07177/08 <br />